guidelines and renal anemia management 2011-2012

Recent guidelines of anemia management 28th May 2011:

Recent guidelines of anemia management 28 th May 2011 DR SAURAV DEKA MD Medical advisor Delhi Mobile :+91- 9717208126 ONLY FOR EDUCATIONAL PURPOSE NOT FOR COMMERCIAL USE

Content :

Content Introduction KDOQI guideline in anaemia management 2002 -2007 CARI guideline 2005-2009 NICE guideline Feb 2011 Indian Guideline 2005 Conclusion

Introduction : Anemia in CKD Appear Together in Individual Patients:

Introduction : Anemia in CKD Appear Together in Individual Patients Hb, hemoglobin; NYHA, New York Heart Association; QoL, quality of life Late 1990s Observation that many patients with CKD and anemia also have CHF Correction of anemia with i.v. iron and ESA in patients with CKD positively affected CKD progression, NYHA class and QoL Observed ~50% of patients with CHF have anemia and that low Hb is related to worse NYHA class Correction of anemia in patients with CHF produced similar results to those observed in patients with CKD and CHF

Studies and Meta-analyses Demonstrate the Links Between CHF, CKD and Anemia:

Studies and Meta-analyses Demonstrate the Links Between CHF, CKD and Anemia I.v. , intravenous; ESA, erythropoiesis-stimulating agent Cardio-Renal Anemia Syndrome (CRAS) The term CRAS is first coined by Silverberg and colleagues (2002) Numerous publications examining the effect of i.v. iron and ESAs in CHF and CKD patients with anemia 2011 KDIGO KDOQI CARI ,NICE etc guideline Working Together to Improve Patient Outcomes Growing evidence and meta-analyses have demonstrated the link between renal failure, heart failure and anemia

The Patient with early stage CKD is 5 to 10 times more likely to die from a cardiovascular event than progress to ESRD.:

The Patient with early stage CKD is 5 to 10 times more likely to die from a cardiovascular event than progress to ESRD. Foley RN, Murray AM, Li S, Herzog CA, McBean AM, Eggers PW, Collins AJ. Chronic kidney disease and the risk for cardiovascular disease, renal replacement, and death in the United States Medicare population, 1998 to 1999. J Am Soc Nephrol 2005; 16:489-95.

So what do we do about this?:

So what do we do about this?

Chronic Kidney Disease:

Chronic Kidney Disease In 1999, the NKF approved a proposal for K/DOQI, Kidney Disease Outcomes Quality Initiative (an evolution of the DOQI (Dialysis Outcomes Quality Initiative). The purpose was to develop clinical practice guidelines for the spectrum of kidney diseases. In February 2002, Clinical Practice Guidelines for Chronic Kidney Disease (CKD): Evaluation, Classification, and Stratification were published. Find the KDOQI guidelines at http://www.kidney.org/professionals/KDOQI/

Primary Goals of CKD Care:

Primary Goals of CKD Care To prevent cardiovascular events and death Heart Attacks Congestive Heart Failure Sudden Cardiac Death Stroke To prevent the progression of CKD to Kidney Failure or ESRD To prevent complications of CKD To prepare for dialysis/transplantation in a timely manner

CRAS is a Vicious Cycle:

CRAS is a Vicious Cycle Anemia Heart failure Renal failure So by preventing Anemia we could meet the first goal

Anemia and CKD:

Anemia and CKD Anemia usually develops during the course of chronic kidney disease and may be associated with adverse outcomes. Anemia is one of the modifiable complications of CKD . All individuals with hemoglobin ( Hb ) levels lower than physiologic norms are considered anemic. Erythropoietin deficiency is the primary cause of anemia of CKD. The NKF recommends that evaluation for anemia should occur when GFR <60 mL/min/1.73 m 2 ; measurement should include Hb level. Anemia should be treated according to the K/DOQI TM guidelines for anemia of CKD.

K/DOQI: Evaluation and Management of Anemia:

K/DOQI: Evaluation and Management of Anemia For Adults with ≥ Stage 3 CKD: Assess Hemoglobin level If anemia (HgB ≤ 12) RBC indices/CBC Reticulocyte count Iron studies Test for occult GI bleeding as indicated Medical evaluation of comorbid conditions Erythropoetin levels are usually NOT indicated.

Prevention of Uremic Complications: Anemia Therapy:

Am J kidney disease 2007;50:471-531 Prevention of Uremic Complications: Anemia Therapy Subcutaneous administration of erythropoietin once to thrice weekly (sometimes less). Supplemental oral or IV iron to keep ferritin > 100 and iron saturation >20%. Monthly monitoring of Hgb , iron stores. Monthly adjustments in EPO dose and frequency to meet target Hgb 11-12 g/dl (HCT 33-36%).

CARI GUIDELINE :

CARI GUIDELINE

What is CARI?:

What is CARI?

What is CARI? Background:

What is CARI? Background Dialysis & Transplantation Committee proposed in Dec 1998 that local clinical practice guidelines were needed KDOQI had just emerged Concerns about applicability beyond US Concerns about being “opinion based” Dec 1998 Steering Committee set up and CARI commenced in 1999

Extensive body of work:

Extensive body of work CKD: Prevention of progression of CKD Nutrition and Growth CV risk VitD , Calcimimetics & PO4 Urine protein Kidney stones Renal vasculitis Dialysis guidelines Acceptance onto Dialysis Biochem and Haem targets Dialysis adequacy Evidence for PD peritonitis Vascular Access Transplantation: Decreased donor suitability CMV and kidney transplantation Calcineurin inhibitors Living Kidney donors

Implementation activities:

Implementation activities Project 1: Iron supplementation in anaemia Mx Conducted 1 st stage of implementation of CARI Guideline on Iron (clinical practice audit, 2005) Published in Medical Journal of Aust Conducting 2 nd stage of implementation of Iron guideline Agreed practice changes and their effect (2006) Currently being analysed

Target Hb CARI Guidelines - 2005:

Target Hb CARI Guidelines - 2005 Minimum Hb concentration in dialysis pts is 11 – 12 gm / dL In CKD Males < 13.5 g/ dL (<12 g/ dL if > 70 years) Female < 11.5 g/ dL

Iron – CARI Guidelines 2005:

Iron – CARI Guidelines 2005 Regular Assessment ( 3 monthly) at initiation of EPO therapy to maintain sufficient iron stores Target Serum Ferritin 200 – 500 ug /L TSAT 30 – 40% Goal is for IV Fe to maintain target Hb without risk of iron overload Delay blood sampling after Iron infusion for 2 weeks as takes time to be absorbed (false low reading)

NICE Guideline for Anemia MX:

NICE Guideline for Anemia M X

NICE Guideline for Anaemia MX:

NICE Guideline for Anaemia M X

NICE Guideline for Anaemia MX:

NICE Guideline for Anaemia M X

NICE Guideline for Anemia MX:

NICE Guideline for Anemia M X

NICE Guideline for Anaemia MX:

NICE Guideline for Anaemia M X

NICE Guideline for Anaemia MX:

NICE Guideline for Anaemia M X

Indian Guideline :

Indian Guideline In 2005 Indian journal of nephrology has published guideline Guideline was mainly for Indian patient Main features were as follows -

When to treat CKD anemia :

When to treat CKD anemia Recommendation a) For males and for post menopausal women Haemoglobin < 12gms% Haematocrit < 36% b ) For pre menopausal women and Adolescents Haemoglobin < 11gms% Haematocrit < 33% c ) EPO therapy should be initiated only after correcting iron, Vitamin B12 and Folic acid deficiency , and other possible factors contributing to anaemia . d ) In patients on haemodialysis haemoglobin concentration to be measured from pre-dialysis sample Indian J Nephrol 2005;15, Supplement 1: S32-S41

Treatment of renal anaemia with EPO:

Treatment of renal anaemia with EPO Recommendation EPO should be administered following group of patients with Hb <12g/dl documented 2 weeks apart with minimum two hemoglobin estimations. - Patients with CKD stage 1-5 developing anaemia . - Patients with CKD stage 5 on Haemodialysis or peritoneal dialysis. Renal allograft recipients with CKD and anaemia . a) EPO should be started at a dose of - 80 - 120IU/ Kg / week b) Once the target Hb is achieved, Hb monitoring should be performed once every month (in HD, CAPD patients & less often in pre-dialysis patients (6-8 weeks). c) 1gm% rise in Hb is necessary with EPO therapy at the end of 2 weeks. EPO dosage can be increased by 50% till the target Hb is achieved. d) If the rise in Hb is > 1.5Gms% at the end of 2 weeks , the dose of EPO to be reduced by 25%

Conclusion :

Conclusion Anemia is the leading co morbid condition associated with CKD Various guidelines has been prepared for management of CKD in Anemia Some differences are there in target level of Hb for treatment start & maintenance But all the guidelines are mostly replicating same Individual patient approach also important for management of Anemia in CKD